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Forms & Resources

Note: All MVP forms and publications are PDF files.

 

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• Claims & Reimbursement Forms

  Wellness Rewards Screening Form
  Medical Reimbursement Form
  Routine Eye Glasses/Contact Lens Reimbursement Form
  Post-Cataract Eyewear Reimbursement Form
  Dental Claim Form
  Hearing Aid Reimbursement Form
  Flu Shot Reimbursement Form

• Pharmacy

  CVS Caremark Mail Service Order Form
  CVS Caremark Medicare Part D Prescription Claim Form
  Coverage Determination Form
  Request for Redetermination of Medicare Prescription Drug Denial
  
  

• Enrollment Forms

  Medicare Part D - Pharmacy Coordination of Benefits (COB) Form
  Disenrollment Rights & Responsibilities
  Disenrollment Form
  

• Publications

  Medicare Medical and Hospital Claims Monthly Report
  Payment Center Help Guide

• Information Release/Authorization

  Authorization to Disclose (ADI) Form
  Actively Employed Information Form
  Appointment of Representative Instructions
  Appointment of Representative Form 
  

• Advance Directives/Advance Care Planning

  New York Advance Directives - What You Need to Know
  NYSBA Living Will and Health Care Proxy Forms
  
  New York State Department of Health
  Organ and Tissue Donations
  Medical Orders for Life Sustaining Treatment (MOLST)
  
  Vermont Department of Health
  Vermont Advance Directive for Health Care
   

• Miscellaneous

  Unclaimed Property Claim Form
  

• Helpful Links

  Medicare.gov (U.S. Government site for Medicare)
  Medicare Ombudsman
  Medicare Complaint Form
  National Coverage Determinations from CMS
  U.S. Social Security Administration
  U.S. Department of Health and Human Services
  New York State EPIC Program
  New York State Office for the Aging
  The Coalition for Medicare Choices
  

 

 

More Forms and Resources

Many forms and publications, such as enrollment forms and your Living Well Newsletter, depend on where you live. Select your county and then click on Forms and Resources on the top of the following webpage.



 

 

Last updated: October 2017

 

Important Information

 

MVP Health Plan, Inc. is an HMO-POS/PPO/MSA organization with a Medicare contract. Enrollment in MVP Health Plan depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

Out-of-network/non-contracted providers are under no obligation to treat MVP Health Plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. Medicare beneficiaries may also enroll in Preferred Gold HMO-POS, GoldValue HMO-POS, GoldSecure HMO-POS, Gold PPO, BasiCare PPO, and/or WellSelect PPO through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.